What is a radical neck dissection? when is it done?

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What is a radical neck dissection? The surgeon removes a block of tissue from the collarbone to the jaw and from the front to the back of the neck. The large muscle on the side of the neck that is used for rotating, flexing or extending the neck is also taken out, along with the major vein on the side of the neck. Sometimes, a less drastic operation, called a supraomohyoid neck dissection is done. This takes out only the lymph nodes, the tissue surrounding the nodes and a muscle at the front of the neck. Another technique, called a functional neck dissection, saves the muscles of the neck, taking out only the lymph nodes and tissues surrounding them.
What kind of incision is made with a radical neck dissection? The incision depends upon what the surgery is for. It can run from below the ear to the collarbone. Everything in the front of the neck on one side or on both sides may be removed. This may include the lymph nodes, blood vessels, nerves, and the salivary gland under the jawbone.

Gallstones and Gallbladder Disease: What are the symptoms of a low functioning gallbladder?

Gallstones and Gallbladder Disease

The gallbladder looks like a partially collapsed toy balloon. It is attached to the underside of the liver, tucked away under the middle of the ribs on the right side. The bile which is produced in the liver from destroyed red blood cells is temporarily garaged in the gallbladder. With meals the gallbladder contracts and passes its bile through the bile ducts into the intestine. Bile facilitates the digestion of fatty foods.

The gallbladder is not necessary for health, digestion or good living. Some animals do not have gallbladders horses and rats, for example, do well without it. In humans, for reasons that are not clearly understood, the fluid content of the gallbladder can change and form stones. These stones within the gallbladder can vary in size from a small pickle to a pebble to sandlike granules. The most frequent problems in gallbladder disease result from the damage these stones do to the organ that contains them. The gallbladder wall may be injured or inflamed, its contents altered, and the egress of bile to the ducts impaired. These symptoms of obstruction and inflammation are often accompanied by impaired digestion and an interference with the satisfactions of eating. Gallbladder problems are common. One in five persons in this country at age fifty has gallstones. Almost threequarters of a million gallbladder operations are done each year in this country.

Patient problems are of two types. There is the ambulatory patient in an office consultation who has had indigestion and has recovered from episodes of pain. This specific type of gallbladder pain is called biliary colic. The other type is the urgently hospitalized person who is sick with infection and obstruction and whose consultation is done in the hospital. This second type is an inflammation of the gallbladder, called acute cholecystitis.

Gallstones (cholelithiasis) - causes, symptoms, diagnosis, treatment & pathology



How can you be sure I have gallstones? 

The only way of being certain is to see the stones on the X-ray film. Bilious symptoms alone may suggest the presence of stones, but they may have their origin in some other organ. Only the X ray is accurate.

How is the X-ray examination done? 

You will be asked to swallow several tablets in the evening before the examination. These contain an iodine compound, which by the next morning will have passed into the gallbladder. An X ray done at that time will show the shape, size and content of the gallbladder. A special fatlike material is then ingested that causes the gallbladder to empty itself. An X ray during this period offers some indication of how well the gallbladder contracts by showing the volumetric percentile discharge of its contents. The diseased gallbladder may not show on the X-ray film, or it may function suboptimally.

If I have gallstones, why do you want to X-ray my stomach too? 

The gallbladder and the part of the stomach and intestine where ulcers occur are very close together; they actually touch one another. Ulcer and gallbladder symptoms can be very similar. Both these X-ray examinations are advised in the interest of making an accurate diagnosis.

Is the X ray ever wrong? Can you always see the stones by this examination? 

The X ray is only a picture; it can't be wrong. What you are questioning is whether the interpretation can be wrong. In the vast majority of instances the stone or stones are obvious it is hard to make a mistake if the films are technically of good quality. Sometimes we don't actually see the stone, but the gallbladder does not appear on the film we use the term "nonvisualization." In 95 percent or more instances this is due to gallstones. On such nonvisualization X rays we assume the presence of stones and a diseased gallbladder, and with very rare exceptions, .it is correct. The diseased organ does not react normally to the ingested iodine tablets because the stones which it generated have impaired its function.

I have a friend who was sick with my same sort of symptoms for many years. The X ray never showed stones, and one day she had to have an emergency operation for pus in the gallbladder.

This is not an unusual experience. The X-ray demonstration of a diseased gallbladder or of gallstones sometimes lags far behind the patient's symptoms of the disease. That is to say, the patient does have a bad gallbladder, often with sandlike gravel, and yet the X ray does not show it. This is a limitation of the X-ray examination. Many experienced surgeons have observed that the patient with serious gallbladder disease may have had a completely normal X ray of this area just a short time before. But the reverse is not true, if the X ray shows the gallbladder is diseased, then it is so when examined during the operation.

Does my indigestion, gaseous feeling, and bloating come from these gallstones? 

Let us say that these symptoms can be associated with a diseased gallbladder, but they may also come from other intestinal disturbances or even from swallowing air or from the irritation induced by smoking.

Shall I have another X-ray examination to be sure that the stones are still there? 

A repeat X-ray study of the gallbladder is not required if the first one showed stones. Stones don't go away by themselves. The only advantage to a repeat X ray is that it now may also show the bile ducts, which may also harbor stones, and whether or not the gallbladder itself is still functioning. Ordinarily, once stones have been demonstrated, the gallbladder is known to be diseased and that is all we need to know. The treatment thereafter is based on symptoms and not on X rays.

Can these symptoms be cured by diet and medication? 

There is no scientific answer to that; actually no one really knows. It is true that some people improve on a special diet. The diet usually suggested is low in fat, based on the concept that if the gallbladder is rested, it won't go into "spasm" and it will heal. Fat in the diet stimulates the gallbladder to contract and to pass the bile into the intestine. Other physicians suggest that the special diet contain some fat to avoid making the gallbladder lazy. In either case, as long as your complaints are not limiting your activities or the capacity to enjoy yourself, the diet is worth trying. Start with a low fat diet and adjust it so that you will also lose some weight at the same time.

For many people there also appears to be an advantage to eliminating highly seasoned food, heavy syrups and chocolate. The dietary approach to this disease is largely empirical. That is, as long as it works for you, that is what counts. You can add or eliminate particular foods as you find them beneficial or provoking.

Some of the very mild sedatives and antispasmodics can also be helpful. These will sort of take the edge off. The physician will evaluate you again in three months, if nothing important happens in the interval, to decide between further dietary management and surgical extirpation.

I've heard of patients who were cured by having their gallbladders washed out twice a week by a stomach tube.Can this help me? 

This is an approach the value of which was questioned even when it was used fifty years ago. It does not cure gallbladder disease, that's definite. The stomach tube is now used only to remove the stomach contents, as part of the treatment for an acute inflammation of the gallbladder.

The pain that I had came on two hours after supper. It was very severe and I had to have an injection to control it. The vomiting was terrible. Could it have come from the Chinese food, cabbage, shish kebab, oysters, Italian food that I ate? 

No one really knows what brings on a "gallbladder attack," although patients often recall that it came on after a particular food or meal. It is uncertain whether this actually initiates the contractions that cause the pain or whether the relationship is one of chance alone. It seems sensible, however, at least for the time being, to avoid that particular food.

What is a gallbladder attack? What causes mine to occur? 

The typical gallbladder attack is a severe and rather sharp pain in the upper abdomen going around the right side or to the right shoulder. It is often associated with retching. The attack is caused by distention of the gallbladder brought on by its contracting against an obstructing stone or hard bit of mucus or other matter. Its very severe component can last as long as one hour.

How is this symptomatically different from gallbladder inflammation? 

Gallbladder inflammation, termed cholecystitis, often has the same pain (colic) as gallbladder attack, but it lasts longer and is accompanied by fever and soreness and tenderness of the abdominal muscles. These symptoms when severe can be confused with a heart attack, a severe lung inflammation, or the passing of a kidney stone. Hospitalization, special X rays, and blood studies may be required to clarify the exact cause of symptoms. Pure biliary colic is not associated with infection or inflammation.

I've only had this kind of attack once. Can you tell me if I'll have another one? Can I travel? 

There is no way of predicting what may happen. You may never have another attack, or it may come on again tomorrow. If attacks come with increasing frequency, then you should consider that the condition will not stay quiet and it should be attended to before you travel. Otherwise you can take a chance on the trip. If you have a problem while away, you can see a doctor there or go to a hospital. (The local hospital is usually able to manage this problem if you become ill en route.) If you are still dissatisfied, you can always fly home. The world is small and one can get around quickly.

Is there any way of dissolving the stones without an operation? Can the stones go away by themselves, by dissolving or passing into the intestine? 

Unfortunately, we have no way of dissolving the stones; there is even no way of making them smaller or moving them. It would be wonderful if we could eliminate the disease by an intravenous injection or by swallowing a drug. Perhaps such a drug will be discovered someday. No such proven method is now available, although the matter is now under active investigation.

Stones can pass by themselves if they are quite small, in which case you will be unaware of it. It is when a large stone tries to pass that you get a typical attack of pain. When the stone gets stuck, it blocks the bile passage, resulting in jaundice and infection. The point you are asking about is whether the stones can pass and thus cure the disease. For practical purposes, it doesn't happen and can't be reliably induced.

What can I do to prevent an attack while I'm deciding about an operation? 

There is no specific remedy even temporarily. That's the brutal truth. Of course, you can be on the diet meanwhile and you should take a laxative to avoid the evil effects of the associated constipation, but there is no assurance that this will help.

Do you remove just the stones or the entire gallbladder? 

The entire gallbladder must be removed, with the stones that it contains; this operation is called a cholecystectomy. This is necessary because stones are formed in the gallbladder, and if it is not removed, new stones may form. At the same time the surgeon may need to remove stones from the ducts. The ducts are not removed, only cleaned out. This complete "cleanout" offers the best chance for a complete cure.

What does the operation accomplish? Can you promise me that I'll be cured and be able to eat everything? After all, that's the only thing that bothers me now. I don't want to have to spend the rest of my life on a restricted diet. 

The purpose of this operation is completely to relieve you of the painful attacks and to prevent infection and obstruction. It is also hoped that the bloating and belching will disappear and that you will be able to enjoy an unrestricted diet. Surgery in this disease is not like tuna fish in a can, where the contents all are the same. The results are not always predictable.

 In one respect the result will depend on how much damage has already been done to the liver, pancreas and bile ducts by the disease. In another regard the result will depend on how thoroughly the surgeon is able to clean out the bile ducts. No one can assure you, as an individual, that these aims will be accomplished. In general, about 90 percent of properly treated individuals are cured of their major problems and about 80 percent are totally free of digestive difficulties. The results of surgery for this disease are, for the most part, extremely satisfactory. But you can see for yourself that the odds are on your promise you that you will fall into the 90 percent group. But you can see for yourself that the odds are on your side. If the operation is unsuccessful, you may remain with the same symptoms that you had hoped would be eliminated.

My husband and I have eaten the same food for twenty years. How come I have gallstones and he's OK? 

If we knew the answer to that question, we might have a clue to how to prevent this disease. The fact that below the age of forty gallstones are more common in women is assumed to be related to bile changes with pregnancy. Gallstones also tend to run in families. The point you make is valid because diet does seem to have a role in the formation of stones. Thus the Yemenites didn't have the disease until they moved northward, the Americanization of the diet in Japan is producing cholesterol stones that previously were uncommon, the disease is extremely common in the American Indian and less common in the black African. The reasons for these disparities are now being investigated, but they are poorly understood.

Will you also take out my appendix through the same incision? 

It is advisable if it can be done easily and if it will not complicate the problem. Many surgeons do this especially in patients below the age of fifty.

 I've known about patients who had to be operated on twice because a stone was left behind the first time. Can this happen to me? How can it be avoided? 


This occurs in about 5 percent of operations done by experienced surgeons. They try to avoid this complication by doing careful surgery and by taking special X rays on the operating table during the procedures to be sure that the ducts are normal, that all stones have been removed, and that the pathway for bile flow is wide open. I can only indicate that the experienced use of special techniques has gone a long way toward eliminating this distressing problem.

My gallbladder was removed fifteen years ago. I was OK for five years. Now I've got the exact same attacks again. What do I do? 

You'll require new X rays to visualize the biliary system. This is done by intravenously injecting a chemical that can then be viewed on the X-ray film. It will show the bile ducts, and by study of their size, shape and contents, it is possible to determine how they are functioning, whether part of the gallbladder has been retained or "re-formed," and whether stones are present in the duct system. The X-ray examination, as well as a few blood tests, is usually adequate to determine whether your new symptoms are coming from this area.

Can stones suddenly appear just like this, fifteen years after an operation? What should I do about it? The stone may have been present at the first operation and not removed or even noticed. A stone can be in the duct for a long time, sometimes a lifetime, without causing symptoms of either pain, obstruction or infection. A new stone can also form in the ducts because the entire system doesn't drain well, in which case this is truly a re-formed stone rather than an old one left behind. It will have to be removed if it causes pain, obstruction or infection. There is no safe, consistently reliable way of removing or dissolving it without surgery.

If it is operated on a second time, what assurance do I have that it won't occur again? 

The precautions that are ordinarily taken by many surgeons the first time are especially carefully carried out the second time. An X-ray examination may indicate the number and position of the stones in the duct. This can serve as a guide. It is a matter of doing the operation very carefully, using all the devices that can help ensure that the ducts are thoroughly cleaned out. These devices can be used at the time of the operation so that before the surgery is completed it is possible to know that all abnormalities have been corrected.

Why wasn't that procedure done at the first operation to prevent this from happening? 

It could or may have been. In most institutions interested in gallbladder surgery or where a great deal of it is done, these precautions are taken and these devices are at hand. In experienced hands and with good facilities, the retained stone problem occurs in not more than 2 percent of patients.

Is this a major operation? Is it risky? 

This is indeed a major operation. In abdominal surgery there are no minor operations. All operations involve risks. But for the most part the surgical techniques and methods for the management of gallstone disease and its complications are well established. In a well-prepared patient experienced abdominal surgeons can accomplish it with an acceptable risk.

How long will I be in the hospital? Will you do any more tests? When will I be able to start doing ordinary housekeeping? 

The average hospital stay is eight to fourteen days. A day or two before the operation it is customary to check the heart and lungs with a cardiogram and chest X ray and to do certain blood tests to see how the liver is functioning. In a realistic way you should not count on doing your ordinary housekeeping for three to four weeks. For that period of time you will require household help. Don't misunderstand. You won't be an invalid, but you're just not going to be up to doing very much. The chores can wait. You should expect to have this operation only once and the other things all the time. Give your operation the priority of time for proper recovery.

Will I need to be on a special diet after the operation? 

No, you should be able to eat virtually everything. But in reintroducing the foods that you had been avoiding, play it cautiously and try one at a time. If any particular one disagrees with you, let it go for a few weeks. If that particular food is important, try it again three to four weeks later.

Why is an emergency operation required now? 

At this time the gallbladder is blocked by a stone, and it is distended and becoming infected. This accounts for your pain, fever and the tenderness when you are examined in this area. The condition is now acute and called acute gallbladder inflammation. In some situations, especially in those patients with diabetes or many previous attacks, it is advisable to take the diseased organ out as soon as the general condition is improved with fluids, antibiotics and a stomach tube. The operation is best done within 72 hours of the time that the diagnosis is confirmed.

I have diabetes and heart trouble. Am I not too old for this kind of surgery?

 In general the person with diabetes and gallstones tends toward serious gallbladder trouble with early infection and gangrene. Therefore, he has to be treated and observed with special precautions.

Some kinds of heart disease like angina may be improved when the diseased gallbladder is removed. The problem should be reviewed with a consultant cardiologist. Calendar age alone doesn't influence the attitude toward treatment; it's how old the patient is in his functioning. If the operation will improve the status of his health, it is worth doing.

I am now yellow in the skin and eyes. What does that mean and what should be done about it?
The yellow color is referred to as jaundice. It indicates a more serious condition than gallbladder colic. In its early stages this important sign may be more obvious to your associates than to you.
It means that the bile in the blood is increased because of a block in the bile system or an infection in the liver. The bile block can be due to a stone, tumor or infection in the ducts, liver or pancreas. In the majority of cases the various blood studies and X rays will reveal the cause. The type of treatment and its effectiveness will depend on the cause of the obstruction.

Do you ever advise not operating on gallstones? 

Obviously one can't, shouldn't and doesn't advise operating on all 20 percent of the population over the age of fifty who have gallstones. Surgeons and physicians differ among themselves and with each other on this problem. Some surgeons believe that no treatment is required where a stone is demonstrated in a patient totally without symptoms. One can't improve the symptoms of the patient who doesn't have any. Other surgeons believe that all stone-containing gallbladders are best removed, symptomatic or not. On the other hand, most surgeons agree that a symptom-producing diseased gallbladder with stones should be removed if the general condition permits.

Is it possible to consider just doing nothing until I get into trouble and then having it done promptly? That's one possibility, but it incurs the risk of not knowing when, where or under what circumstances the complication may occur. But, of course, you are correct in that it may never occur. This is a gambler's approach.

The X ray is said to show a pinhead-size lump in the gallbladder. I feel perfectly well. Do I need an operation for this? 

Ordinarily gallbaldder removal is not necessary for this X-ray finding. It can be an inborn, unimportant odd shape, or a small stone, or a clump of glands or a cholesterol deposit. We -aren't concerned anymore that these are cancers. You should have the X-ray studies repeated later to see what is happening. If it has increased in size, or you develop symptoms that are not psychological, or you can't help worrying about it, then perhaps you should have it removed.

Is the liver involved in gallbladder disease? 

Yes and no. Yes in the sense that some believe that the abnormality in the liver bile produces the gallstones. Yes also in the sense that neglected severe disease of the gallbladder and bile ducts can produce infections and even abscesses in the liver. The answer is no in that those liver changes that result from the diseased gallbladder are completely cured by the complete correction of the gallstone problem.

Is there any possibility that the formation of gallstones can be eliminated in the near future?
Evidence suggests that the constituents in the bile can be changed by altering the intake of certain fatty acid drugs or certain bile acids. Experimentally they appear to dissolve stones in particular instances in some animals,but their broad application to patients is being studied. It is a good area for research. The world would be grateful for the solution to this common problem. It would eliminate the commonest operation in abdominal surgery. This would be a sure way of deserving the Nobel Prize.

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